New Blood Pressure Guidelines Draw Fire

Dissenting medical experts from panel warn that new rules could endanger some people

En español l It sounded like great news for thousands of older people: New blood pressure guidelines might free them from the anxiety of taking powerful medications to control their blood pressure, and the side effects those pills sometimes brought.

But almost immediately, several members of the panel of medical experts recommending the change strongly dissented and warned that the new guidelines could endanger some people.

The result has been confusion similar to that created late last year with the muddled rollout of new guidelines for using cholesterol-lowering statin drugs.

The controversy began when a panel of 17 national experts announced in December that, based on a five-year analysis of the best available research, the target for treating high blood pressure should be nudged a little higher for those age 60-plus and for those with diabetes or kidney disease. Its findings were published in the Journal of the American Medical Association.

However, five panel members disagreed and published a follow-up article in the Annals of Internal Medicine warning that the change could put more patients at risk for heart disease and stroke.

The American Heart Association has also resisted the change, saying that it could undermine recent progress in reducing deaths from these conditions.

"Hypertension is such a strong risk factor, especially if you have other diseases. This is not the time to loosen control over blood pressure," says the group's president, Mariell Jessup, M.D., medical director of the University of Pennsylvania's heart and vascular center.

Guidelines from the previous panel in 2003 defined high blood pressure in older adults as 140/90 or above, meaning that's the threshold for taking medication to bring those numbers down. (The top number represents the pressure inside the arteries when the heart beats, and the bottom number is the pressure between beats, when the heart rests.)

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The new guidelines change nothing if you're younger than 60. But if you're 60 or older, the target has moved up: Your goal is to keep your blood pressure at 150/90 or lower. If you have kidney disease or diabetes, your target used to be 130/80 or lower; now it's 140/90 or lower.

Raymond R. Townsend, M.D., director of the hypertension program at the University of Pennsylvania and a member of the panel that wrote the new guidelines, says that the change is based on the best available data from randomized controlled trials, considered the gold standard for scientific evidence.

But every patient is different, he says. And while "some will be better off with blood pressure at 130, others whose blood pressure is running 140 to 146, and [who are] already on 11 medications, don't need to add a 12th pill to lower their blood pressure to 138. A doctor's judgment trumps guidelines."

The dissenting panel members, however, say the evidence isn't strong enough to support raising the bar from 140 to 150 for everyone older than 60.

According to Jackson T. Wright Jr., M.D., author of the minority view and director of the clinical hypertension program at University Hospitals Case Medical Center in Cleveland, it could leave older adults with untreated high blood pressure at greater risk for complications — especially for African Americans and those with additional cardiovascular risk factors.

Wright, who was also a member of the 2003 panel, supports sticking with those recommendations to treat blood pressure that is above 140/90.

"With that target, the complication rate has been decreasing over the past several decades, especially in those over age 60," he says. By following the new guidelines, "we may face a reverse in these gains."

Still, both doctors and patients worry about the side effects of blood pressure meds, particularly dizziness that can lead to falls, and how the pills interact with the other medications a patient may be taking. By adding some leeway in treating high blood pressure, patients may be able to take fewer pills, says Townsend.

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The one thing the controversy points up is that "each patient needs to be individualized," says the heart association's Jessup.

"A blood pressure of 150/90 in one patient who's basically in good health, but might need to make some dietary or lifestyle changes, is not the same as another one with 150/90 who is a walking time bomb because they have other risk factors," she points out.

Mary Ann McLaughlin, M.D., medical director of the cardiac health program at Mount Sinai Medical Center, says that, since news of the guidelines, "many patients have called and emailed me asking if they can get off their pills."

Her general advice:

If you're older than 60 and on more than two blood pressure medications, and your blood pressure is consistently in the 120s or 130s, talk to your doctor about revisiting your regimen.

If you're older than 75 and feeling dizzy or light-headed with a systolic blood pressure (top number) less than 150, talk to your doctor about reducing your medication dosage.

If you're active and vigorous at any age on your current medication regimen, and your systolic blood pressure is less than 140, there should be no reason to change your medications.